International Journal of Nursing Practice 2016; 22: 43– 52

CLINICAL PAPER

Bridging nursing practice and education through

a strategic global partnership
Marilyn Stringer PhD, CRNP, RDMS, FAAN
Professor Emerita of Women’s Health Nursing, Family and Community Health, University of Pennsylvania School of Nursing,
Philadelphia, Pennsylvania, USA

Lakshmi Rajeswaran PhD RN

Lecturer in Nursing, School of Nursing, University of Botswana, Gaborone, Botswana

Kefalotse Dithole PM, RN, PhD (candidate)

Lecturer in Nursing, School of Nursing, University of Botswana, Gaborone, Botswana

Linda Hoke PhD RN, CCNS, ACNS-BC, CCRN

Clinical Nurse Specialist, Cardiac Intermediate Care Unit, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

Patricia Mampane BSN, RN, RM

Unit Manager, Infectious Diseases Care Clinic, Princess Marina Hospital, Gaborone, Botswana

Sheila Sebopelo BSN, RN

Infection Control Officer, Nursing, Princess Marina Hospital, Gaborone, Botswana

Margret Molefe MSN, RN, RM

Former Senior Nursing Officer, Ministry of Health, Gaborone, Botswana

Marjorie A Muecke PhD RN, FAAN

Assistant Dean, Global Health Affairs, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Associate Director, WHO Collaborating Center for Nursing & Midwifery Leadership, Philadelphia, Pennsylvania, USA

Victoria L Rich PhD RN, FAAN

Chief Nurse Executive, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
Associate Professor, Nursing Administration, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA

Rosemary C Polomano PhD RN, FAAN

Professor of Pain Practice, Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Professor, Anesthesiology and Critical Care (Secondary), University of Pennsylvania Perelman School of Medicine, Philadelphia,
Pennsylvania, USA

Accepted for publication June 2014

Correspondence: Rosemary C. Polomano, Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418
Curie Blvd, Philadelphia, PA 19104, USA. Email: polomanr@nursing.upenn.edu

doi:10.1111/ijn.12362 © 2014 Wiley Publishing Asia Pty Ltd

44 M Stringer et al.

Stringer M, Rajeswaran L, Dithole K, Hoke L, Mampane P, Sebopelo S, Molefe M, Muecke MA, Rich VL, Polomano
RC. International Journal of Nursing Practice 2016; 22: 43– 52
Bridging nursing practice and education through a strategic global partnership

To forge strong relationships among nurse scholars from the University of Pennsylvania School of Nursing, Philadelphia,
PA (USA); University of Botswana School of Nursing, Gaborone, Botswana; the Hospital of the University of Pennsyl-
vania, Philadelphia; Princess Marina Hospital (PMH), Gaborone; and the Ministry of Health of Botswana, a strategic global
partnership was created to bridge nursing practice and education. This partnership focused on changing practice at PMH
through the translation of new knowledge and evidence-based practice. Guided by the National Institutes of Health team
science field guide, the conceptual implementation of this highly successful practice change initiative is described in detail,
highlighting our strategies, challenges and continued collaboration for nurses to be leaders in improving health in
Botswana.
Key words: evidence- based practice, global partnerships, nursing education, nursing practice, team science.

INTRODUCTION
Global nursing partnerships between countries with pro-
gressive health-care systems and developing countries are
vitally important to advancing nursing science, education
and practice, yet a recent review reports only 15 publi-
cations addressing such partnerships, with most focused
on educational parterships.1 Many schools of nursing in
the United States of America (USA) have established pro-
ductive global health programmes demonstrating mutual
benefits for students, clinicians and researchers.2–6
Clearly, methodologies and models for exemplary part-
nerships inform the global nursing community as to
optimal ways to build capacity for sustaining lasting and
impactful global relationships.3,7 Programmes that focus
on developing global emerging leaders are especially
valuable in transforming health care in sectors of the
world.
The University of Pennsylvania (UPenn) and the Uni-
versity of Botswana (UB) have had 10-year collaboration
among several disciplines, focusing on building capacity to
improve health outcomes in Botswana. For nursing, a
partnership between the UPenn School of Nursing Dean
and some faculty and UB’s Head of the Nursing School has
existed for several years, with exchange programmes for
Visiting Professorships; UPenn faculty providing research
consultations in Botswana; and UB hosting UPenn students
in community health. In 2008, nurse leaders and front-line
care nurses from the Hospital of the University of Pennsyl-
vania (HUP), Philadelphia, PA, USA, visited Princes
Marina Hospital (PMH) in Gaborone, Botswana, to initiate
foundational work to advance education and clinical prac-
tice. During this initial visit, trusting relationships were
formed, and a mutual vision was set for PMH to begin its
journey towards practice excellence, with the long-term
goal of applying for the American Nurses Credentialing
Center (ANCC) Pathways to Excellence® Program and
eventually the Magnet Recognition Program® for desig-
nation of nursing and organizational excellence. The
HUP team conducted comprehensive education in basic
infection prevention and control practices, emergency
responses to critical patient events, and principles of
authentic leadership. Subsequently, another UPenn and
HUP team visited Gaborone in 2009 to promote interdis-
ciplinary evidence-based palliative care practice through a
5 day workshop.8
Challenges in health care at PMH and
nursing education at the UB
Botswana is a democratic county situated northwest of
South Africa with a 2013 estimated population of
2 127 825.9 Since 2010, the Ministry of Health (MOH)
assumes oversight for all health-care services in Botswana,
including serving as the decision-making body for decid-
ing employment settings for nurses within the health-care
system. Professional nurses in Botswana do not always
have the same opportunities as USA nurses in choosing
their specialization in nursing or where they prefer to
work. The state of nursing in Botswana is fully described
in a comprehensive review that emphasizes the growing
population health problems, notably a high prevalence of
HIV/AIDS and current status of the nursing workforce,
including a nursing shortage.10 As of 2006, the ratio of
nurses was 28.8 per 100 000 people, which falls in the
low range of 10 to 100 nurses per 100 000 people for

© 2014 Wiley Publishing Asia Pty Ltd

Bridging Nursing Global Partnerships
developing countries.11 Not unique to Botswana,
increased work demands are responsible for poor satisfac-
tion among nurses in developing countries, but factors
such as low status, limited autonomy and low pay are also
associated with nurse dissatisfaction.12 PMH has over 550
beds; however, challenges in patient throughput related
to delays with transitions in care and increasing patient
volume often lead to a unpredictable fluctuating daily
patient census exceeding bed capacity. This necessitates
the placement of overflow beds, which results in changes
in staffing and scheduling practices that all too frequently
require nurses to care for greater numbers of patients.
Botswana clinical nurses at PMH do have policies to guide
their practices, but have fewer practice resources such as
evidence-based practice (EBP) guidelines and limited
access to research publications to guide independent and
interprofessional decision-making. One goal of this
project was to expand the clinical resources accessible to
Botswana clinical nurses and to assist in the translation of
EBP guidelines to clinical care.
The historical background and current state of nursing
education in Botswana are thoroughly discussed in a
recent 2012 publication where it is reported that over 5
years, Botswana diploma schools have produced approxi-
mately 3000 graduates, whereas UB School of Nursing
in Gaborone, the only school in Botswana offering a
Bachelor’s degree, graduated around 80 to 100 nurses
annually.13 UB has several graduate programmes in
advanced practice nursing, and doctorally prepared
faculty who actively pursue research to advance the
science of nursing. UB faculty also supervise student clini-
cal experiences at PMH.
To expand a global nursing partnerships between
UPenn and entities in Botswana, a grant-funded (UPenn
Tiffany Foundation) project enabled work to forge strong
relationships among nurse scholars from the UPenn
School of Nursing, Philadelphia, PA (USA); UB School of
Nursing, Gaborone, Botswana; the HUP, Philadelphia;
PMH, Gaborone; and the MOH of Botswana. The
primary aims of the project were to: (i) engage nurse
scholars from education, research, practice and adminis-
tration in work to advance the scientific foundations for
EBP and research utilization at the PMH; (ii) align educa-
tion with practice by preparing nursing faculty and prac-
tice leaders to collaborate in addressing health problems
and issues of greatest concern to the well-being of the
citizens of Botswana. Here, we present our experiences in
forming and executing this strategic global partnership.
45
METHODS
The UPenn-Botswana Nursing Team Collaboration
Model was conceived through an interaction and integra-
tion model adapted from the Collaboration and Team
Science: A Field Guide published by the National Institutes of
Health, USA.14 This field guide served as the structural
framework to assemble model components for practice,
education, leadership and research, and direct processes
for team building and accomplishing mutual goals. This
team science collaboration incorporated the mission,
vision and values from the UPenn and UB Schools of
Nursing to engage global leaders in advancing the art and
science of professional nursing and fostering strategic
partnerships to propose and test solutions in response to
the current challenges facing Botswana nursing practice
leaders and faculty. Pressing issues for Botswana nurses
centered on the delivery of quality and safe patient care
through access to clinical resources to support practice
(e.g. evidence-based guidelines and best practices),
empowering nurses to engage in interprofessional col-
laboration as the basis for team-based care, and forming
productive relationships between nursing practice leaders
and faculty to bridge education and practice. By adapting
and implementing the Collaboration and Team Science: A
Field Guide, it was possible to devise a stepwise approach
to accomplish work by the UPenn-Botswana nursing
team: (i) planning stages for change; (ii) building a team
of scholars (team selection and membership, fostering
trust and ground rules); (iii) establishing a shared vision;
(iv) navigating and leveraging networks and systems;
(v) strengthening team dynamics; and (vi) addressing the
challenges. Figure 1 shows the level of interactions in
sequential phases of collaboration and team science.
Planning stages for change
To expand the UPenn-Botswana collaboration, in early
2012 the head of the UB School of Nursing visited the
UPenn School of Nursing as the Dean’s International Vis-
iting Scholar. During her visit, a new direction for the
inter-school partnership was defined that would promote
intra-nursing collaboration across education, practice and
policy in Botswana. The plan involved UPenn Nursing
hosting five Botswana nurses from academia, practice and
the government for a month-long immersion experience
at UPenn for exposure to university nursing education and
tertiary hospital health care. This experience would allow
Botswana colleagues to chart their course for desired
change in their academic and practice settings based on
© 2014 Wiley Publishing Asia Pty Ltd
46
Level of Interaction and Integration
Low
Building a Team and
Planning Stages for Establishing a
Change Shared Vision
Febraury 2012 to
October 2012 April 2012 to May
2012
Building a
Team of
Scholars
Planning
Establishing a
Shared Vision
perceived priorities, available resources and feasibility of
change. The head of the UB School of Nursing returned to
Botswana to identify five nurse scholars to partner with
UPenn faculty to advance this collaboration.
The UPenn team subsequently secured an internal
grant (UPenn Tiffany Foundation Grant) to accomplish
and build a stronger strategic partnership with colleagues
in Botswana. The grant supported a 4 week experience
(June 2012) in the USA for five Botswana scholars and a 2
week visit (September 2012) to Botswana by three UPenn
faculty. UPenn’s Nursing Global Health Affairs Office
(Assistant Dean, author MAM) served as the administra-
tor for the grant coordinating all travel and housing
arrangements for the Botswana and UPenn teams, and
orientation of Botswana visitors to UPenn.
Building a team of scholars
Team selection and members
The UPenn-Botswana team included five Botswana nurse
leaders selected for their ability to influence changes in
education, practice and research. The team consisted of a
PhD-prepared UB faculty member (author LR) and
Masters-prepared PhD candidate faculty member (KD),
two registered nurses (RNs) with administrative roles in
patient safety from PMH (PM and SS) and the chief nurse
for the Botswana Ministry of Health (MM). This was the
first collaboration between these two UB faculty members
and three nurse leaders from practice. The UPenn team
consisted of three PhD-prepared nurses (MS, RCP, LH).
MS and RCP are UPenn Standing Faculty-Clinician Edu-
cator (CE) Track and nurse scientists at the HUP, and
© 2014 Wiley Publishing Asia Pty Ltd
M Stringer et al.
High
Botswana Scholars
Visit UPenn June 2012
UPenn Faculty Visit
Gaborone, Botswana
September 17 to
October 1, 2012
Navigating and
Leveraging
Networks,
Systems
Strengthening
Team Dynamics
Addressing the
Challenges
Figure 1. Phase-specific collaborative team model.
both hold secondary appointments in departments at the
UPenn Perelman School of Medicine. LH is a Clinical
Nurse Specialist (CNS) whose primary appointment is at
the HUP. The three UPenn and HUP nurse scholars were
selected for their ability to influence practice, education
and research across academic and clinical settings. Each
has a strong background in cultivating successful collabo-
rations among health-care professionals in practice and
faculty.
Fostering trust and ground rules
The eight-member UPenn-Botswana team communicated
through Skype calls from March to May 2012 to establish
priorities for the month-long visit by Botswana colleagues
in June 2012. As part of team building and mentoring, the
UPenn faculty applied the Covey’s interdependence
framework, which includes three concepts: (i) ‘Think
Win-Win’, by striving for mutually beneficial solutions or
agreements; (ii) ‘Seek First to Understand, Then to be
Understood’, by creating an atmosphere of caring,
empathic listening and positive problem -solving skills
with an open mind and cultural sensitivity; and (iii)
‘Synergize’, by combining the strengths of the individual
team members to achieve the goals no one person could
have done alone.15 Managing conflicts and disagreements
and keeping lines of communication open are essential for
successful team building; therefore, the UPenn-Botswana
team adapted a technique often used in health care known
as ‘Crucial Conversations’, for conflict resolution.16 Pref-
erences for how team members wanted to be acknowl-
edged and credited for their work were discussed with
Bridging Nursing Global Partnerships 47

Table 1 Key guiding principles in global nursing partnership teams to advance education and practice: lessons learned from the UPenn-
Botswana collaboration

Use a framework to guide collaboration to achieve mutual expectations and goals.

• Select a framework that embraces structures, processes and outcomes.
• Determine how the framework will support the collaboration.
Engage the ‘right’ team members who are in the ‘right’ positions to influence change.
Establish ‘ground rules’ for the partnerships:
• Promote open and respectful communication.
• Identify roles each team member will assume.
• Agree on time commitments required to sustain the partnership and related work.
• Consider preferences for how each entity and individuals wish to be recognized and credited for the work.
• Apply communication principles such as ‘crucial conversation’ to keep lines of communication open and authentic.
Set priorities of greatest need and interest to stakeholders to bring about change.
Avoid imposing practices or cultural values that conflict with ‘norms’.
• Be sensitive to the fact that the educational and clinical practices in one country might not be realistic, feasible or accepted in another
country.
• Allow global partners to experience the diverse educational and practice environments.
• Tailor practice changes for the best chance of success.
Develop and implement innovations that can be tested for scope of impact and value to promoting positive changes.

efforts to provide opportunities for both the Botswana and
UPenn faculty to demonstrate global scholarship and build
academic dossiers. Table 1 outlines key guiding principles
implemented with our global nursing partnership.
Providing cultural experiences
Building a highly functioning global team requires dedi-
cated work and recreation to provide opportunities to
build caring, functional relationships. To cultivate cul-
tural awareness and personal relationships, social activ-
ities were included such as shopping, dining at local
eateries, and relaxing gatherings at UPenn and Botswana
team member’s homes. In the USA, sightseeing trips to
historic Philadelphia, New York City, and Washington
DC were arranged for Botswana visitors. Although
in Botswana, the UPenn team attended a traditional
wedding reception and observed religious worship. The
Botswana concept of ‘Botho’ was extended to the
UPenn team with traditional cuisine, and visits to urban
and rural attractions around Gaborone. In both coun-
tries, visiting teams had an insider’s view on health-care
delivery.
Establishing a shared vision
Guided by Donabedian’s model of structure process and
outcomes,17 the UPenn-Botswana team collaborated over
a 2 month period with bi-monthly Skype calls to plan the
4-week immersion experience in the USA. A weekly
schedule was created targeting content themes based on
the Botswana team’s priorities for bringing about change
in nursing education and practice, and fostering their pro-
fessional and personal development.
• Week One: Teaching strategies and EBP
• Week Two: Palliative care and quality improvement
• Week Three: Learning strategies and peer review
• Week Four: Patient safety and project development
Figure 2 highlights examples of structures, processes
and outcomes for the UPenn immersion experience for
Botswana scholars. Simultaneously, the team discussed
how UPenn faculty would offer their expertise and
provide mentorship in practice, education and research
during their visit to Botswana in September 2012.
Communicating about science
Communication around the scientific foundations for
practice and education required a global perspective that
encompassed internationally accepted EBP guidelines
and best practices. Although advancements in these
areas are known around the world, the UPenn-Botswana
team examined relevant science that guides clinical care
across the globe. It was particularly important to discuss
bringing about changes in practice in Botswana by

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48
Figure 2. Application of Donabedian’s model highlighting examples of the UPenn-Botswana partnership to meet identified priorities for changes in
practice and education at PMH and UB. PMH, Princess Marina Hospital; UB, University of Botswana; UPenn, University of Pennsylvania.
carefully considering the translation of science into prac-
tice based on cultural values, feasibility, resources and
acceptance of authoritative sources of scientific evidence
by Botswana health-care providers. Global literature-
based methodologies and resources and recommendations
were drawn from international professional organizations
and societies.
Navigating and leveraging networks
and systems
Botswana colleagues’ visit to the UPenn
One lead UPenn team member assumed responsibility for
coordinating all learning experiences for a given week,
arranging for transportation, collecting and distributing
scientific materials and other resources, and providing
primary mentorship to the visiting scholar team. Experi-
ences included classroom learning in both academic and
clinical settings, daily team debriefing sessions, cultural
experiences and collaborative team work to design a
© 2014 Wiley Publishing Asia Pty Ltd
M Stringer et al.
translational science project ready for implementation
when Botswana scholars returned to Gaborone.
Kirkpatrick’s Model of Learning Evaluation served as
the framework for navigating and leveraging networks
and systems for specific learning activities and methods of
evaluation for the USA site visit18 (see Table 2). While in
the USA, Botswana team members were all given access
to UPenn’s library resources and training in conducting
literature searches by a UPenn librarian. Each Botswana
scholar received an iPad purchased through grant funds to
retrieve and store electronic resources.
On the academic side, Botswana scholars attended
classes on research, women’s health and global health.
Uniquely, they observed the three UPenn Standing-CE
Track faculty (authors MS, RCP, VLR) bridge academia
and practice in their professional roles. Opportunities
were provided to meet with several UPenn faculty
members who had visited Botswana and/or were
engaged in ongoing research in Botswana to exchange
Bridging Nursing Global Partnerships 49

Table 2 Adaptation of Kirkpatrick’s levels of learning evaluation13

Level Evaluation type Evaluation description and Examples of evaluation Relevance and practicability
(what is measured) characteristics tools/methods

UPenn Experience for Botswana scholars

1 Reaction Reaction evaluation is how the
delegates felt about the
training or learning experience.
2 Learning Learning evaluation is the
measurement of the increase in
knowledge—before and after.
Botswana scholars’ work behaviors upon return to Botswana:
putting learning into action
3 Behaviour Behaviour evaluation is the
extent of applied learning
back on the job—
implementation.
Daily and weekly debriefing sessions
Daily critiques of learning
experiences
Reflective learning
Journaling
Botswana clinical nurses and nurse
leaders:
• Participated in interdisciplinary
team meetings/rounds
• Implemented new patient care
practices post-surgical patients
• Developed new documentation
tools and evaluation of nursing
care outcomes
• Utilized the Rapid Results
Methodology to bring about
change in patient care.
Learning experiences and practices
were consistently evaluated for
feasibility within the Botswana
education and health-care
system.
Newly learned leadership and
clinical practices were adapted
to conform to cultural norms.
New practices were trialled and
evaluated by clinical staff.
Realistic timelines were established
to implement new patient care
practices.

4 Results
Results evaluation is the effect
on the business or
environment by the trainee.
Botswana nurse scholars led an
interdisciplinary team in
implementing an Enhanced
Recovery Critical Pathway for 45
adult male surgical patients over a
5 month period.
Newly integrated practices in the
care of surgical patients were
expanded to other patient
populations and units.

powerful stories about changes in the Botswana health-
care system.
For clinical care at HUP, Botswana scholars spent time
with nurse leaders, clinical educators and advanced prac-
tice registered nurses. They experienced several nursing
leadership and interprofessional meetings to observe effec-
tive collaboration and communication. All Botswana visit-
ing scholars spent time on patient care units witnessing first
hand how HUP clinical nurses formulate plans of care,
make autonomous clinical decisions, and collaborate
with physicians and other health-care professionals in
team-based care. Prevention strategies and monitoring of
nursing-sensitive outcomes, along with best practices,
centered on hospital-acquired pressure ulcers (HAPUs),
central line-associated blood stream infections (CLABSIs)
and catheter-associated urinary tract infections (CAUTIs).
Botswana scholars met with HUP EBP Committee mem-
bers to discuss how projects are initiated and EBP guide-
lines influence care. To experience how nurses are
empowered to direct and affect change through interpro-
fessional collaboration, Botswana scholars attended
Unit-based Clinical Leadership (UBCL) meetings where
physicians, nurses and other care team members in leader-
ship roles collaborate to share accountability for unit- and
patient population-specific performance improvement
outcomes.
Every Friday, the Botswana team dedicated time
to reflect on the week’s experiences, and observed

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50
leadership, clinical and educational practices that could
realistically be translated into their health care and aca-
demic settings as well as those that would not be feasible
at the time. The UPenn-Botswana team also worked on
the design of critical care pathway to structure and guide
nursing care on the most challenging unit at PMH—the
Male Surgical Ward (MSW). The team agreed on the
Rapid Results Methodology or Initiative (RRI) (originally
conceived in Africa) as the framework for the project to
improve care for general surgery patients. The RRI meth-
odology uses the progressive implementation of quality
initiatives to bring about meaningful change in 100 days.19
A draft was assembled for an ‘Enhanced Recovery Surgical
Critical Pathway’ with the intent of improving patient
outcomes such as pain, nutrition and activity, and reduc-
ing the length of hospitalization for patients on the MSW
from 7 to 10 days to 3 to 5 days. The pathway incorpo-
rated EBP guidelines for pain care, patient monitoring and
other aspects of post-surgical care. At the completion of
the month-long immersion experience, structures and
processes were planned for a successful programme
implementation in Botswana.
Botswana scholars return to Gaborone
Upon their return to PMH and UB, the Botswana team
informed key stakeholders about their experiences in the
USA, and shared educational and practice resources with
colleagues. They engaged nurses, physicians, pharmacists
and other health professionals and support service
members in work to refine the critical pathway appropri-
ate for the general surgical male population. The UPenn-
Botswana team continued to engage in frequent Skype
calls to seek approval of the critical pathway protocol by
the PMH Ethics Committee, UB Institutional Review
Board and MOH.
UPenn team visit to Botswana
Approximately two and half months following the return
of the Botswana team to Gaborone, the three-member
UPenn team (authors MS, RCP and LH) arrived in Gabo-
rone to begin their 2 week immersion experience. It was
evident that the Botswana team had already strengthened
their relationships with officials from the MOH, the UB
faculty leaders from the School of Nursing and Medicine,
and nursing and physician leaders from PMH. The UPenn
team went into action presenting over 15 in-service and
grand rounds programmes for nurses and physicians
and teaching in the school of nursing, reaching over 300
clinicians, faculty and students in total.
© 2014 Wiley Publishing Asia Pty Ltd
M Stringer et al.
To support practice and the implementation of the
research-based ‘Enhanced Recovery Surgical Critical
Pathway’, the UPenn-Botswana team collaborated with
anaesthetists, surgeons and clinical nurses to develop a
comprehensive post-surgical pain protocol that capitalized
on evidence-based multi-modal analgesic strategies for
aggressive pain control20,21 and EBP patient monitoring
practices22 with broad applicability to various surgical
populations. Importantly, this protocol used the RADAR
approach (Responsibility, Anticipation, Discussion,
Assessment and Response) to promote interdisciplinary
pain care and underscore that pain management should be on
everyone’s radar.23 Approximately 75 international and
USA EPB guidelines, research publications and review
articles were compiled to support clinical decision-
making in post-surgical care.
An all-day workshop sponsored by the MOH for 37
area nursing leaders and educators was held to highlight
the critical pathway project and to teach aspects of prac-
tice leadership for achieving excellence in clinical care.
While In Botswana, the UPenn team visited various facil-
ities such as health clinics, a health post and a remote
mobile stop where Botswana nurses work to experience
the transitions in levels of care.
Strengthening team dynamics
The initial time invested in strategic global planning was
successful in strengthening team dynamics over time. This
strategy of methodical planning, team building, and use of
frameworks and models to explicate the strategic work
and its evaluation proved invaluable in achieving strategic
goals. Now separated by over 7000 miles, the UPenn-
Botswana team continues to communicate regularly by
Skype to complete the Enhanced Recovery Surgical Criti-
cal Pathway Project and discuss new opportunities for
advancing the scientific foundations for nursing education
and practice.
DISCUSSION—ADDRESSING
THE CHALLENGES
The UPenn-Botswana Nursing Collaboration is an expan-
sion of a strong existing partnership that has enabled
student experiences, faculty research and collaborations
among academic leaders. However, our collaboration
involved a new team of emerging leaders in Botswana and
UPenn nursing faculty, and this specific collaboration
spanned practice, education and research training. Our
challenges were not unique in initiating a productive
Bridging Nursing Global Partnerships
partnership; however, our initial planning addressed one
important challenge. To be successful in endeavours to
change practice through the translation of new knowledge
and EBP guidelines in developing countries, representa-
tives from these countries need to experience practice
environments that successfully accomplish these chal-
lenges, and have time to assimilate these experience. As
such, the immersion experience at UPenn allowed our
Botswana team to determine the feasibility of adopting
changes in practice and prioritize those having the greatest
impact on the health and well-being of their patient popu-
lations. Moreover, when USA representatives visit devel-
oping countries to influence change, they can be more
prepared and focused if they, too, have an a priori under-
standing of the current health-care challenges. Others
have emphasized the importance of identifying specific
needs, developing strong and sustained partnerships, and
addressing barriers by creating and trialling effective solu-
tions to ongoing challenges.24
The National Institutes of Health team science field
guide with a team science focus was extremely beneficial
in streamlining our work. Other models served as the
foundational frameworks for planning and organizing the
course of action and defining measureable outcomes for an
integrative approach embracing training in practice, edu-
cation and research. Model-driven global partnerships
incorporating team science must account for a universal
understanding of the contextual interpretations, and this
includes team science. Stokols et al.25 provide an excellent
analysis of the contextual influences on transdisciplinary
collaboration with team science, and we found this espe-
cially useful in our efforts to engage physicians and other
health-care professionals at PMH and UB in the critical
pathway research project for male surgical patients. Inter-
estingly, they emphasized the importance of measuring
the effects of every team science interdisciplinary encoun-
ter. As an example, during an interdisciplinary team
meeting at PMH, the UPenn-Botswana team discussed the
scientific basis for interventions to prevent surgical com-
plications, especially the need for early mobilization.
Patients on the PMH MSW often remained in bed some-
times way beyond 24 h following surgery. The next day,
several chairs were delivered to the ward as a result of
actions taken by one of the PMH surgeons. In response to
another interdisciplinary encounter underscoring the
need for pain reduction strategies with multimodal anal-
gesia, a pharmacist took measures to increase the avail-
ability of specific analgesics.
51
Other challenges not often easily managed were issues
related to resource allocation for implementing EBPs in a
developing country. For example, the pain protocol for
post-surgical patients had to be adjusted to include analge-
sic agents that were available and accessible. Opioid-based
regimens for pain control on general care wards could not
be maximized due to the lack of opioid medications. The
UPenn team remained sensitive to these issues, and
attempted to introduce EBP guidelines, research-based
practices and clinical support tools that were universally
accepted throughout the world and not just those unique
to the USA. At times, language barriers presented a chal-
lenge as meanings were lost in translation. Distance com-
munication was difficult, with disruptions in Internet
connections and email. Compensated faculty and clinician
efforts at UPenn, PMH and UB were especially pro-
blematic as this effort required the dedicated work of
many individuals, including clinical nurses whose work
demands were increased as a result of our project for
surgical patients. Often, lead UB nursing faculty research-
ers and PMH leaders had to assume additional responsibil-
ities in the clinical care. The success of implementing a
new evidence-based care pathway for surgical patients at
PMH and the engagement of an interdisciplinary care
team made this experience a most rewarding one.
ACKNOWLEDGEMENTS
This collaboration was partially supported by funding
from the University of Pennsylvania (UPenn) Tiffany
Foundation Grant and in-kind support from UPenn, UB,
PMH and the Botswana Ministry of Health. The authors
wish to express their gratitude to Afaf I. Meleis, PhD,
DrPS(hon), FAAN, Margaret Bond Simon Dean of
Nursing, UPenn School of Nursing, Motshedises Sabone,
PhD, RN, Head of the UB School of Nursing, and Harvey
Friedman, MD, Director of the Botswana-UPenn Part-
nership and Professor of Medicine, UPenn Perelman
School of Medicine for their continued support for the
UPenn-Botswana Nursing Collaborative. A special thanks
to Geralyn Grosso for all her efforts in supporting the
logistics of this global partnership.
REFERENCES
1 George EK, Meadows-Oliver M. Searching for collabora-
tion in international nursing partnerships: A literature
review. International Nursing Review 2013; 60: 31–36.
2 Harper DC, Davey KS, Fordham PN. Leadership lessons
in global nursing and health from the nightingale letter
© 2014 Wiley Publishing Asia Pty Ltd
52
collection at the University of Alabama at Birmingham.
Journal of Holistic Nursing 2014; 32: 44–53.
3 Vermund SH, Sahasrabuddhe VV, Khedkar S, Jia Y,
Etherington C, Vergara A. Building global health through a
center-without-walls: The Vanderbilt Institute for Global
Health. Academic Medicine 2008; 83: 154–164.
4 Koplan JP, Baggett RL. The Emory Global Health Institute:
Developing partnerships to improve health through
research, training, and service. Academic Medicine 2008; 83:
128–133.
5 Bosworth TL, Haloburdo EP, Hetrick C, Patchett K,
Thompson MA, Welch M. International partnerships to
promote quality care: Faculty groundwork, student pro-
jects, and outcomes. Journal of Continuing Education in
Nursing 2006; 37: 32–38.
6 Lasater K, Upvall M, Nielsen A, Prak M, Ptachcinski R.
Global partnerships for professional development: A Cam-
bodian exemplar. Journal of Professional Nursing 2012; 28:
62–68.
7 Powell DL, Gilliss CL, Hewitt HH, Flint EP. Application of
a partnership model for transformative and sustainable
international development. Public Health Nursing 2010; 27:
54–70.
8 Ersek M, Sebego M, Bloom AM, Shaibu S, McMenamin E,
Mokotedi M. Development and evaluation of an interna-
tional, interdisciplinary palliative care workshop in Bot-
swana. International Journal of Palliative Nursing 2010; 16:
13–21.
9 Central Intelligence Agency. The World Factbook. 2013.
Available from URL: https://www.cia.gov/library/
publications/the-world-factbook/fields/2119.html.
Accessed 1 March 2014.
10 Sinha N, Onyyatsteng G. The nursing labour market in
Botswana: An economic analysis. PULA: Botswana Journal of
African Studies 2102; 26: 109–124.
11 World Health Organization. World Health Statistics 2012.
Geneva: World Health Organization, 2012.
12 Mrayyan MT. Jordanian nurse’s job satisfaction, patients’
satisfaction and quality of nursing care. International Nursing
Review 2006; 53: 224–230.
13 Seboni NM. Chapter 2: Botwsana. In: Klopper HC, Uys LR
(eds). The State of Nursing and Nursing Education in Africa: A
Country-By-Country Review. Indianapolis, IN: Sigma Theta
Tau International, 2013; 25–40.
© 2014 Wiley Publishing Asia Pty Ltd
M Stringer et al.
14 Bennett L, Gadlin H, Levine-Finley S. Collaboration and
Team Science: A Field Guide. Bethesda: National Institutes of
Health, 2010.
15 Covey S. The Seven Habits of Highly Effective People. New
York: Free Press, 2004.
16 Patterson K, Grenny J, McMillan R, Switzler A. Crucial
Conversations Tools for Talking When Stakes are High, 2nd edn.
New York: McGraw-Hill, 2011.
17 Donabedian A. Evaluating the quality of medical care. The
Milbank Quarterly 2005; 83: 691–729.
18 Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Pro-
grams: The Four Levels, 3rd edn. San Francisco, CA: Berrett
Koehler Publishers Inc, 1994.
19 Sylvester O. Rapid Results Approach / Initiative: Institu-
tionalization of Results Based Management in Kenya Public
Service. Available from URL: http://www.capam.org/
_documents/rapidresultsapproach.kenya.pdf. Accessed 20
June 2013.
20 Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical
pain: Risk factors and prevention. Lancet 2006; 367: 1618–
1625.
21 Macintyre PE, Scott DA, Schug SA, Visser EJ, Walker SM
(eds.). Australian and New Zealand College of Anaesthetists
and Faculty of Pain Medicine: Acute Pain Management Sci-
entific Evidence (3rd ed.). 2010. Available from URL:
http://www.anzca.edu.au/resources/college-publications/
pdfs/Acute%20Pain%20Management/books-and-
publications/acutepain.pdf. Accessed 10 August 2013.
22 Jarzyna D, Jungquist CR, Pasero C et al. American Society
for Pain Management Nursing guidelines on monitoring for
opioid-induced sedation and respiratory depression. Pain
Management Nursing 2011; 12: 118–145.
23 Vickers A, Bali S, Baxter A et al. Consensus statement on
the anticipation and prevention of acute postoperative pain:
Multidisciplinary RADAR approach. Current Medical
Research and Opinion 2009; 25: 2557–2569.
24 Rybak N, Koster M, Gilbert EB, Flanigan T. Building inter-
national collaborations from the ground up: Brown univer-
sity partnerships in Haiti and Ukraine. Rhode Island Medical
Journal 2013; 96: 33–37.
25 Stokols D, Hall KL, Taylor BK, Moser RP. The science of
team science: Overview of the field and introduction to the
supplement. American Journal of Preventive Medicine 2008; 35
(2S): S77–S89.